complaint·April 10, 2025

The investigation consisted of the following: On 12/04/2024 Licensing Program Analyst (LPA) Troy Watson reviewed / obtained Resident Roster (dated 12/2024), Staff Roster (dated 12/2024), and Emergency Disaster Plan. Interviews were conducted, with Staff #1 – Staff #8 (S1-S8) and Residents #1- Residents#7 (R1-R7). The facility grounds were toured. Investigation revealed the following: Allegation: Staff do not ensure facility fire alarm is in good repair. It is alleged that the smoke detector is broken and randomly goes off unexpectedly in the facility disturbing its residents. On 12/04/24 LPA Watson interviewed Staff#1 – Staff#8 (S1-S8) regarding the allegation. Of those interviewed 8 out of 8 staff agreed to the allegation. On 12/04/24 LPA Watson interviewed Residents #1- Residents #7 (R1-R7); 7 out of 7 residents interviewed agreed with the above allegation. On 12/04/24 LPA Watson interviewed Executive Director Clifton Douyon. During the interview, Douyon stated that the smoke detectors located in room 118 and 221 were dysfunctional and needed repair. The director explained that they sounded off intermittently because of construction work being performed on the facility ceiling. During the interview it was also revealed that the triggering of the second smoke alarm was due to rainwater from the roof top of the ceiling. On 12/05/24 LPA Troy Watson interviewed and toured the facility grounds with the Maintenance Director Glen Olano, During the tour LPA observed and confirmed that the smoke detectors in rooms 118 and 221 were disconnected, and not functioning. During the interview Olan stated that an order for replacement or repair of the smoke detectors had been placed with Johnson Controls. LPA Watson requested records and called Johnson Controls to confirm the estimated time of repair or replacement of the smoke detectors multiple times. No confirmation of parts ordered or an estimated time of arrival for repairs could be confirmed. Based on evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Therefore, the allegation according to the California Code of Regulations (Title 22, Division 6, Chapter 8) has been Substantiated . The following deficiencies have been observed and a citation issued (ref. LIC 9099-D) An exit interview was conducted with the Executive Director, Clifton Douyon and a hard copy of this report was provided.